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Wounds can be closed primarily in the emergency department (ED) by the placement of sutures, surgical staples, skin closure tapes, and adhesives. All wounds heal with some scarring; however, preferred closure techniques make scars less noticeable. It is important to match each layer of a wound edge to its counterpart. Care must be taken to avoid having one wound edge roll inward. The rolled-in edge promotes wound infection as well as misaligns the dermis and epidermis causing wound dehiscence and increased scarring.
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Sutures are the strongest, most reliable and adaptable of all wound closure devices allowing the most accurate approximation of wound edges. Sutures are classified as nonabsorbable and absorbable. The latter lose all their tensile strength within 60 days. Monofilament synthetic sutures such as nylon or polypropylene have the lowest rates of infection and are the most commonly used suture material in the ED. Synthetic monofilament absorbable sutures (eg, Monocryl®) are preferred for closure of deep structures such as the dermis or fascia because of their strength and low tissue reactivity. Rapidly absorbing sutures (eg, Vicryl Rapide®) can be used to close the superficial skin layers or mucus membranes, especially when the avoidance of removal is desired.
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Sutures are sized according to their diameter. For general ED use, 6-0 suture is the smallest and is used for percutaneous closure on the face and other cosmetically important areas. Suture sizes 5-0 and 4-0 are progressively larger; 5-0 is commonly used for closure of hand and finger lacerations, and 4-0 is used to close lacerations on the trunk and proximal extremities. Very thick skin, as is found on the scalp and sole, may require closure with 3-0 sutures.
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Percutaneous sutures that pass through the epidermal and dermal layers are the most common sutures used in the ED. Dermal or subcuticular sutures reapproximate the divided edges of the dermis without piercing the epidermis. These two sutures may be used together in a layered closure as wound complexity demands. Sutures can be applied in a continuous fashion (“running” sutures) or as interrupted sutures.
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Simple Interrupted Percutaneous Sutures
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Place percutaneous sutures to achieve eversion of the wound edges. The needle should enter the skin at a 90° angle and exit the opposite side at 90°. The depth of the suture should be wider than the width. Sutures placed in this manner will encompass a portion of tissue that will evert when the knot is tied (Fig. 10-1). Place an adequate number of interrupted sutures to close wound edges without gaping. In general, the number of ties should correspond to the suture size (ie, 4 ties for 4-0 suture and 5 ties for 5-0 suture).
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